Case Study Near Drowning

7/30/2019 Case Study Near Drowning

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Case Study:Case Study:Near DrowningNear Drowning

Annabelle SmithAnnabelle Smith

RN,RN, BScNBScN

Case Study:

Near Drownin

Annabelle Smith

RN, BScN

Conclusion: Near DrowningConclusion: Near Drowning

Effects on surfactant key to treatmentEffects on surfactant key to treatment

requirements and survivalrequirements and survivalInitial hypothermia may be protective toInitial hypothermia may be protective toCVS & neurological systemsCVS & neurological systems

Water source importance debatable onWater source importance debatable onoutcome resultsoutcome results

Amount of water & length in elementsAmount of water & length in elementsmore importantmore important

Outline: Case StudyOutline: Case Study

DefinitionDefinition NearNear

Presentation ofPresentation of

PathophysioloPathophysiolo

Review of cReview of c

ConclusioConclusio

Near DrowningNear Drowning

AkaAka submersion injurysubmersion injury

survival, at least temporarily aftersurvival, at least temporarily after

suffocation by submersion in a liquidsuffocation by submersion in a liquid

mediummedium

wetwet near drowningnear drowning -- aspiration of fluidaspiration of fluid

into lungsinto lungs

drydry near drowningnear drowning period of asphyxiaperiod of asphyxia

secondary tosecondary to laryngospasmlaryngospasm

Near Drowning SyndromeNear Drowning Syndrome

Depends on:Depends on:

Duration of submersionDuration of submersion

Amount of fluid aspiratedAmount of fluid aspirated

Severity of hypoxiaSeverity of hypoxia

One tough little ladyOne tough little lady

Aboriginal, 73 year old femaleAboriginal, 73 year old female

PMHX: DM2; HTN; HypothyroidismPMHX: DM2; HTN; Hypothyroidism

PSHX:PSHX: CholecystectomyCholecystectomy; R knee replacement; R knee replacementMedsMeds

ASAASA AmitriptylineAmitriptyline

NorvascNorvasc

LipitorLipitor

EnalaprilEnalapril

GlyburideGlyburide

MetforminMetformin

AvandiaAvandia

LL--thyroxinethyroxine

One tough little ladyOne tough little lady

October 1 @ 1800October 1 @ 1800

Hunting moose in the Island Lake waterHunting moose in the Island Lake watersystem, Northern Manitobasystem, Northern Manitoba

Fell out of canoe while trying to assist herFell out of canoe while trying to assist hergroupgroup

Submerged for unknown amount of timeSubmerged for unknown amount of time

Son performed rescue breathingSon performed rescue breathing

Walked over an hour to STP nursingWalked over an hour to STP nursingstationstation


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@ STP nursing station@ STP nursing station

Initial vitals:Initial vitals:

Pulse 74Pulse 74 Resp. rate 30Resp. rate 30--4040

Temperature 30 degrees CTemperature 30 degrees C

O2O2 satssats-- unable due to tempunable due to temp

NeuroNeuro: intact: intact

EKGEKG-- no acute changes; sinus rhythmno acute changes; sinus rhythm

C/S: crackles to bases; pink frothy sputumC/S: crackles to bases; pink frothy sputum

Projectile emesisProjectile emesis

RBS: 22.6RBS: 22.6

DuringDuring MedivacMedivac TransferTransfer

FrequentFrequent desaturationsdesaturations during flightduring flight

c/o:c/o: GeneralizedGeneralized

painpain

SOBSOB

CoughCough

Arrives @ HSCArrives @ HSC

T 34 P 84 BP 96/59 RR 32T 34 P 84 BP 96/59 RR 32

O2O2 satssats with 15L 92%with 15L 92%

GCS 15/15GCS 15/15

Transferred to MICUTransferred to MICU

RR 53RR 53

BIPAPBIPAP

RespResp crackles at basescrackles at bases

PathophysiologyPathophysiology

Drowning begins with:Drowning begins with:

Period of panicPeriod of panic

Loss of normal breathing patternLoss of normal breathing pattern

Breath holdingBreath holding

Air hungerAir hunger

Struggle by victim to stay aboveStruggle by victim to stay abovewaterwater

Aspiration > 11 ml/kg of bodyAspiration > 11 ml/kg of body

weightweightbefore blood volumebefore blood volumechanges occurchanges occur

Aspiration > 22 ml/kg of bodyAspiration > 22 ml/kg of body

weight before electrolyte changesweight before electrolyte changes

occuroccur

Patient outcomes affected by:Patient outcomes affected by:

Initial treatment & time toInitial treatment & time totreatment centretreatment centre

Temperature of waterTemperature of waterLength of submersion timeLength of submersion time

Presence of contaminantsPresence of contaminants

Freshwater / saltwater differentFreshwater / saltwater differentmicroorganismsmicroorganisms


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Patient outcomes affected by:Patient outcomes affected by:

Gram negative bacteria in drowningGram negative bacteria in drowning

victims more virulentvictims more virulentCan cause immediate lethal sepsisCan cause immediate lethal sepsis

or infections months after incidentor infections months after incident

Strep or staph can also be presentStrep or staph can also be present

Fungus: incubation time 1Fungus: incubation time 1--4 weeks to4 weeks to

6 months; often resistant6 months; often resistant

Near Drowning: Pulmonary EffectsNear Drowning: Pulmonary Effects

Pulmonary insufficiency can developPulmonary insufficiency can develop

insiduouslyinsiduously or rapidlyor rapidlyLeads to varying degrees of hypoxemiaLeads to varying degrees of hypoxemia

s/ss/s::

SOBSOB

RalesRales

WheezingWheezing

CXR / CT: vary from normal to localized,CXR / CT: vary from normal to localized,perhilarperhilar, or diffuse pulmonary edema, or diffuse pulmonary edema

Causes of HypoxemiaCauses of Hypoxemia

ReflexReflex inspiratoryinspiratory efforteffort

Damage to surfactantDamage to surfactant

Decreased lung complianceDecreased lung compliance

Ventilation perfusion mismatchingVentilation perfusion mismatching

Intrapulmonary shuntingIntrapulmonary shunting

causes diffuse organ dysfunctioncauses diffuse organ dysfunction


Surface tension properties of surfactantSurface tension properties of surfactant

affectedaffected

SurfactantSurfactant washed outwashed out

Water in alveoliWater in alveoli

Damages type 2Damages type 2 pneumocytespneumocytes

Prevents production of new surfactantPrevents production of new surfactant

Loss of surfactant functionLoss of surfactant function


Alveoli become unstableAlveoli become unstable

Complete/partial alveolarComplete/partial alveolar

collapsecollapseLoss of ventilation resulting inLoss of ventilation resulting inintrapulmonary shunting &intrapulmonary shunting &hypoxemiahypoxemia


Increased airway resistance secondary to:Increased airway resistance secondary to: Plugging of airway with debrisPlugging of airway with debris

Release of inflammatory mediators that resultRelease of inflammatory mediators that resulton vasoconstrictionon vasoconstriction

May impair gas exchangeMay impair gas exchange

CombinationCombination damage todamage toalveolar capillaries &alveolar capillaries &interstitiuminterstitium leads to ARDSleads to ARDS


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ARDS: develops within 48 hours inARDS: develops within 48 hours in

approximately 40% ofapproximately 40% of

neardrowningneardrowning

victimsvictims Hallmarks of ARDS:Hallmarks of ARDS:

Decreased lung complianceDecreased lung compliance

Severe hypoxemiaSevere hypoxemia

Bilateral infiltrates on CXRBilateral infiltrates on CXR

Recovery occurs in 80% of casesRecovery occurs in 80% of cases

Only effective treatment is reversal ofOnly effective treatment is reversal ofhypoxemia with mechanical ventilatorhypoxemia with mechanical ventilatorsupportsupport

Neurologic EffectsNeurologic Effects

Hypoxemia & ischemia causeHypoxemia & ischemia cause

neuronal damageneuronal damageCan produce cerebral edema &Can produce cerebral edema &

elevation in ICPelevation in ICP

20% sustain neurologic damage20% sustain neurologic damage

limits functional recoverylimits functional recovery

Cardiovascular effectsCardiovascular effects

Arrhythmias secondary toArrhythmias secondary to

hypothermia & hypoxemiahypothermia & hypoxemia

SinusSinus bradycardiabradycardia && atrialatrial fibrillationfibrillation

more common than ventricularmore common than ventricular

fibrillation orfibrillation orasystoleasystole

AcidAcid Base & ElectrolytesBase & Electrolytes

Metabolic & respiratory acidosisMetabolic & respiratory acidosis

Significant electrolyte balances do notSignificant electrolyte balances do notgenerally occur except those submergedgenerally occur except those submergedin unusual mediain unusual media

Dead Sea: extremely concentratedDead Sea: extremely concentratedseawater leads to:seawater leads to:

HypernatremiaHypernatremia

HypermagnesemiaHypermagnesemia

hypercalcemiahypercalcemia

Renal EffectsRenal Effects

Failure rarely occursFailure rarely occurs

If it doesIf it does

Usually due to acute tubular necrosisUsually due to acute tubular necrosisResults from:Results from:

HypoxemiaHypoxemia

ShockShock

HemoglobinuriaHemoglobinuria

MyoglobinuriaMyoglobinuria

Back to our case studyBack to our case study

Respiratory complication:Respiratory complication:

BipapBipap Oct 2Oct 2 44thth

ABG Oct 2:ABG Oct 2:

7.41 / 33 / 92 / 217.41 / 33 / 92 / 21

Pre intubation furtherPre intubation furtherdecompensationdecompensation::7.42 / 35 / 60 / 227.42 / 35 / 60 / 22

SatsSats: 88% with decrease to 20% during intubation: 88% with decrease to 20% during intubation

attemptsattempts

CXR : bilateral edemaCXR : bilateral edema


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Case study contCase study contdd

Required AC ventilation with paralysisRequired AC ventilation with paralysis

FentanylFentanyl;; midazolammidazolam;; propofolpropofol; &; & rocuroniumrocuroniumAC : ARDS net protocol ventilation with trials ofAC : ARDS net protocol ventilation with trials of

PSV for 8 daysPSV for 8 days

Hospital day 11: able to tolerate PSV ventilationHospital day 11: able to tolerate PSV ventilation

Hospital day 14: transfer to Seven Oaks HospitalHospital day 14: transfer to Seven Oaks Hospital

ICUICU

PSV 20; peep 14PSV 20; peep 14

ABG: pO2 76;ABG: pO2 76; satssats 9494

CXR resultsCXR results

Oct 2: bibasilar pulmonary opacitiesOct 2: bibasilar pulmonary opacities

with probable bilateral pleuralwith probable bilateral pleuraleffusionseffusions

Oct 3: opacities predominate inOct 3: opacities predominate in

mid/lower lungs; significantmid/lower lungs; significant

progression; pulmonary edemaprogression; pulmonary edema

Oct 4: @ 0830Oct 4: @ 0830-- no new changes; laterno new changes; later

in dayin day-- R sided effusion;R sided effusion; intubatedintubated

CXR results contCXR results contdd

Oct 5: worsening L base R/TOct 5: worsening L base R/T pulmpulm..

Edema or ARDSEdema or ARDS

Oct 6: extensive alveolarOct 6: extensive alveolar

consolidationconsolidation

Oct 10: extensive bilateral opacitiesOct 10: extensive bilateral opacities

and consolidation; ARDSand consolidation; ARDS

Oct 11: increasing degree ofOct 11: increasing degree of

consolidationconsolidation

Culture ReportsCulture Reports

Oct 3: MSUOct 3: MSU-- >10*8 E. Coli>10*8 E. Coli

Oct 4:Oct 4:

SPTSPT -- 3+ PMN; 4+ GPC; 3+ GPB; 1+ GNB3+ PMN; 4+ GPC; 3+ GPB; 1+ GNB

ETTETT 4+ PMN; 1+ GPB; 2+ GPC; 1+ GNB4+ PMN; 1+ GPB; 2+ GPC; 1+ GNB

Positive ETT secretions: strep pneumoniaPositive ETT secretions: strep pneumonia& staph& staph aureusaureus

Temp did not elevate; WBC elevatedTemp did not elevate; WBC elevated

ABxABx:: cefuroximecefuroxime;; cefotaximecefotaxime;;

azithromycinazithromycin; &; & vancomycinvancomycin

Renal FunctionRenal Function

Scanty urinary output throughout hospitalScanty urinary output throughout hospital

staystay

LasixLasix usedused

On transfer: fluid balance +On transfer: fluid balance +veve: 17 L: 17 L

CreatinineCreatinine rise to 85 (admission 67)rise to 85 (admission 67)

No dialysis requiredNo dialysis required

Possible GI bleed (no source found)Possible GI bleed (no source found)

HgbHgb drop to 68drop to 68

CTCT abdabd: normal: normal

CT brain: normalCT brain: normal


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PatientPatients final outcomes final outcome

Transferred out of Seven Oaks ICU toTransferred out of Seven Oaks ICU to

general wardgeneral ward

Died November 15, 2007 due toDied November 15, 2007 due to

persistent pulmonary issuespersistent pulmonary issues


Effects on surfactant key to treatmentEffects on surfactant key to treatment

requirements and survivalrequirements and survivalInitial hypothermia may be protective toInitial hypothermia may be protective toCVS & neurological systemsCVS & neurological systems

Importance of water source debatable inImportance of water source debatable inregards to treatment & patient outcomeregards to treatment & patient outcome


Be vigilantBe vigilant..

Be preparedBe prepared

ItIts a matter of times a matter of time

Appropriate, aggressive respiratory &Appropriate, aggressive respiratory &

multisystem support is the keymultisystem support is the key

Be vigilant

Be prepared

Its just a matter of

time

Appropriate,

aggressive respiratory

& multisystem support

is key

QUESTIONS ???QUESTIONS ???

Questions???


Effects on surfactant key to treatmentEffects on surfactant key to treatmentrequirements and survivalrequirements and survival

Initial hypothermia may be protective toInitial hypothermia may be protective to

CVS & neurological systemsCVS & neurological systemsWater source importance debatable onWater source importance debatable onoutcome resultsoutcome results


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Case Study Near Drowning